Provider Demographics
NPI:1467615898
Name:BOGARD, SHYRLENA L (MD)
Entity Type:Individual
Prefix:
First Name:SHYRLENA
Middle Name:L
Last Name:BOGARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2759
Mailing Address - Country:US
Mailing Address - Phone:815-780-5029
Mailing Address - Fax:
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:BLDG B
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2763
Practice Address - Country:US
Practice Address - Phone:815-223-2944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126361207VG0400X, 207VX0000X
IL036.126361261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126361Medicaid
IL036126361Medicaid